If the FCRC or LTC-ADI decides that a transfer does not meet one of the allowable transfer criteria (see PM 07-02-20-b), the transfer is non-allowable. If the net value of all transfers is $5,000 or less, determine if the transfer is allowable and, if not, calculate the length of the penalty period. If the net value of all transfers is more than $5,000, complete a referral packet using the HFS 3654A and send to HFS Long Term Care - Asset Discovery Investigation (LTC-ADI) for review (see PM 07-02-20-a). For non-allowable transfers, customers are subject to a penalty period for nursing home (NH), SLF, and DoA HCBS waiver services (see NOTE). If otherwise eligible, the person remains entitled to other covered medical services.
NOTE: Persons with a penalty period who are eligible for QMB benefits remain eligible for LTC services during the benefit period in which Medicare-covered SNF services are received.
For NH and SLF cases, do not allow a deduction from income for NH or SLF expenses and/or charges for DoA HCBS services incurred during a penalty period. For NH, SLF, or DoA HCBS waiver cases, do not allow these expenses to meet any spenddown amount. This applies whether or not the person received benefits during the penalty period.
When multiple non-allowable transfers are reported, combine them and treat them as a single transaction. Determine a single penalty period, equal to the total length of time (including partial months) the uncompensated amount (see NOTE below) of resources transferred meets the person's monthly (30-day) LTC costs at the private rate. There is no maximum penalty period.
- For nursing home cases, use the private rate at the facility where the person lives.
- For SLF cases and for persons applying for or receiving DoA HCBS waiver services, contact the Bureau of Long Term Care at (217) 782-0545 for the long term care private rate to use in the calculation.
NOTE: The uncompensated amount is the fair market value of each transferred resource, minus any value received for the resource. The total uncompensated amount is equal to the sum of the uncompensated amounts for each non-allowable transfer made.
The beginning date of the penalty period is the later of:
- the date the person becomes otherwise eligible for NH, SLF, or DoA HCBS waiver services (including meeting any spenddown and following any days fully covered by Medicare);
- the first day of the month during which the transfer for less than FMV is made; or
- The first month that can be affected for an ongoing case allowing for timely notice to be sent to the customer.
- Example 1: Mr. R has a non-allowable transfer of $50,000 which results in a 10-month penalty period. When he applies 09/01/13, he has SSA income of $1,800 per month and a short-term annuity paying $4,000 per month. He also has $750 in medical bills. The caseworker compares his income, minus medical bills, to the private pay rate of $5,000 per month and determines that he is not income eligible. The application is denied.
- Mr. R reapplies 03/01/14 after the annuity payments have ended. He is now income eligible and the case is approved with a 10-month penalty from March through December 2014.
Once a penalty period is decided, it applies until the end of the calculated period unless events change regarding the transfer. Therefore, if the person leaves a facility and returns at a later date or stops receiving benefits and reapplies at a later date, the initial penalty period continues in effect until the end of the calculated period. Recalculate the end date of the penalty period so that it picks up with the remaining months of the penalty.
- Example 2: Ms. B has completed 5 months of an 8-month penalty period. She goes home for 4 months. When she returns to the LTC facility, the caseworker codes the end date of the penalty period to reflect that she is ineligible for 3 more months.
An LTC penalty period for non-allowable transfers may include partial months (WAG 07-02-20-d). When an NH or SLF customer has a partial month of eligibility due to a penalty period, enter the admission date on the HFS 2299 by writing the first day the customer is eligible at the top of the form. (Completion of HFS 2299, as described, is OPTIONAL. Entry of new data and revision of existing data may instead be done in the MMIS LTC subsystem.)
- Example 3: Mr. Y applies for LTC assistance 09/01/12. He had a non-allowable transfer of $3,200 six months before application. The monthly LTC private payment rate is $5,310. Mr. Y is ineligible for .61 months ($3,200 ÷ $5,310 = .602; round up to two decimals). This makes Mr. Y ineligible for 18.3 days (30 days X .61). The admission date entered is 09/19/12, the first day of eligibility and coverage. Mr. Y has $53 remaining ($177 daily rate X .3) from the penalty period to pay as the group care credit on 09/19.
Continue to apply Mr. Y's income and resources to any remaining days in the month after the penalty period expires. Enter the amount of the customer's NH credit or SLF credit and any remaining penalty liability in the MMIS LTC subsystem or on the HFS 2299. Complete the HFS 458LTC, Notice of Decision on Application for Medical Assistance - MANG Long Term Care/Supportive Living Facility, with the first day or partial day of eligibility.
- Example 3, continued: Mr. Y receives $900 monthly from Social Security and has $300 in countable resources. He is eligible for 12 days in September with a private pay rate of $2,124 ($177 daily rate X 12 days). Using the two-step budgeting process (PM 15-04-04), the caseworker determines that Mr. Y is eligible. Mr. Y has $923 in NH credit for his care for September ($900 SSA - $30 personal allowance + $53 remaining penalty = $923). The caseworker enters $923 for September. The FCRC sends the HFS 458LTC to Mr. Y and the facility to notify them that his coverage begins 09/19/12.
- For October, Mr. Y will have $870 NH credit ($900 - $30).
- Example 4: Ms. M transferred resources worth $16,650 for less than FMV in August 2012. She entered an LTC facility with a monthly private payment rate of $5,050, applied for medical assistance, and was determined eligible beginning 09/15/12. Ms. M has a 3-month, 9-day penalty based on the non-allowable transfer ($16,650 ÷ $5,050 = 3.297, rounded to 3.3; 30 days X 3.3 = 99 days). Her penalty runs 09/15 - 10/14 (month 1); 10/15 - 11/14 (month 2); 11/15 - 12/14 (month 3); plus the remaining 9 days of penalty (12/15 - 12/23). The FCRC enter 12/24 as the admission date on the HFS 1156.
For Department on Aging Community Care (HCBS waiver) cases, add the amount of the unused penalty to the customer's income for the month to reflect the partial month of ineligibility.
- Example 5: Mrs. S receives $1,200 SSA benefits, has $500 in countable resources and a non-allowable transfer of $6,800 that occurred three months before application. She applied for medical benefits in September 2012. Using the Community Care rate of $5,430 ($181 per day), the caseworker determines that Mrs. S is ineligible for 1.26 months ($6,800 ÷ $5,430 = 1.252). Mrs. S is ineligible for September and part of October. After using $5,430 for September, Mrs. S has $1,370 plus her regular income to pay for her care in October. Mrs. S has a spenddown of $1,614 for October ($1,200 SSA + $1,370 penalty balance - $25 income disregard - $931 AABD medical standard). The FCRC enters $1,614 as her income spenddown for October and $244 for November because the penalty will no longer apply ($1,200 SSA - $25 income disregard - $931 AABD medical standard). The FCRC sends a decision form (360 series) to Mrs. S informing her that she is eligible beginning in October with a $1,614 spenddown. The FCRC sends the IL444-360L to notify the Community Care provider that the case has been approved, effective October.